Tom Widger has been closely involved in the study of suicide in Sri Lanka for over 10 years. He is the author of several academic articles on suicide in Sri Lanka and is co-editor of Ethnographies of Suicide, a special issue of Culture, Medicine and Psychiatry.

After a decade of decline, Sri Lanka’s suicide rate – once among the highest in the world – is reported to be on the rise once again. It’s too early to tell whether this is a temporary blip or the beginnings of something more serious. But what is known is that the fall in the suicide rate was the result of "means restriction" – chiefly banning the most toxic pesticides – not falling levels of suicide attempts overall. Although Sri Lanka has gained a reputation for progressive agrochemical regulation as a result, the evidence suggests that the number of suicide attempts has actually increased, with suicidal behaviour remaining a leading cause of serious injury and death in the country.

The relation between suicide and culture is one that suicidologists are finally starting to take seriously. As suicide rates rise across Asia (a region already reporting more than 60% of the world’s suicides), many experts are questioning the validity of prevention programmes developed in and for Euro-American contexts. Although the methods by which people harm themselves or commit suicide might be universal, how, why, and with what consequences suicidal behaviours are performed are always culturally specific. If the very practice of suicide is culturally variant, intervention strategies should be too.

In the Euro-American context, many people understand suicide to be the result of deep-seated psychological illnesses like depression – up to 90% of cases by most estimates. Suicidal ideas and plans often develop over a period of days, weeks, or even months, meaning that family and friends have opportunities to spot danger signs and intervene. People contemplating suicide might start hoarding medicines or talking about life after they’re gone; they might complain about being "trapped" by circumstances beyond their control and of not knowing how to escape. Thoughts like these can be enough to encourage suicidal people to seek professional help or for others to encourage them to do so.

But in Sri Lanka, suicidal behaviours more often seem to arise impulsively, with little or no warning. Researchers working on suicide in the country, including psychiatrists, psychologists, sociologists, and anthropologists, agree that only a minority of suicide cases are linked with depression – somewhere between 10% and 40%, depending on whom you ask (and many wouldn’t accept the application of a western diagnostic category at all). Instead, a family quarrel or sudden disappointment might cause feelings of overwhelming suffering, frustration, and anger, leading to the swallowing of poison as a public statement. Suicidal ideas and plans more often develop in a matter of hours or even minutes – leaving very little time for family or friends to see the danger signs and intervene.

This difference poses real challenges for suicide prevention in Sri Lanka. It’s not clear at which point, between the precipitating event and resulting act of self-harm, interventions can be made. It’s also not clear what, beyond means restriction, might even be appropriate. Frontline mental health providers increasingly favour the prescription of antidepressants, even though the majority of those who self-harm are demonstrably not depressed. Beyond this, there are currently several prevention programmes active in Sri Lanka, some run by government agencies and others by local and international non-governmental organisations. Many share the view that suicide is ultimately a mental health problem that can be tackled through counselling, or that resilience to suicidal ideas can be imparted through life-skills training. Although these programmes are designed and run by excellent and committed professionals, the jury’s still out as to whether they can bring about lasting change.

A crucial problem is cost. Given the sheer size of the suicide and self-harm epidemics, the government would struggle to provide services at the scale and depth required. Local suicide prevention and mental health charities fail to attract funds from within Sri Lanka, and now the country has obtained middle-income status, international donors are looking to put their money elsewhere. In the competition for resources, suicide – a difficult problem even in better circumstances – loses out to more treatable (and politically relevant) health problems like cancer or diabetes.

But sustainability might be achieved if interventions are designed so they are culturally, socially, and medically equitable.

First, prevention programmes need to be designed with local meanings of suicide in mind – they need to be culturally equitable. Simply applying global solutions to a local problem is inefficient. Greater fit between how suicidal people understand the causes of their behaviour and how professionals respond to those understandings can reduce the risk of wasted resources and lead to better patient outcomes. This will require rethinking how self-harm is defined in Sri Lanka, from its current designation as a mental health problem to one that takes into consideration its cultural roots. A rethink of this kind is not easy, and much work needs to be done. It calls for interdisciplinary cooperation between health and social researchers and the maintenance of a dialogue over time.

Second, prevention programmes need to avoid reproducing the inequalities leading to suicide in the first place – they need to be socially equitable. In Sri Lanka, suicidal behaviours are widely performed to bring attention to relational conflicts, often some kind of maltreatment or abuse. Typical examples include violence against children and women, and attempts to control women’s bodies either sexually or in terms of women’s migration overseas. A large number of men’s suicides are performed in response to challenged masculinities. In these contexts self-harm offers an important – if risky – opportunity for communication when others aren’t available. Limiting that opportunity can mean limiting a person’s ability to bring about change in their lives – an ethically contentious proposition. Health workers must honour their pledge to save lives but also to do no harm. As tends to currently be the case, psychosocial counselling shouldn’t end with returning patients to an abusive domestic environment. This will require greater cooperation between agencies, for example mental health and social services, so care between the hospital and the community is streamlined.

Third, greater cultural and social equity can lead to enhanced medical equity. Faced with suicidal behaviours that don’t fit the textbook definition of depression, too many frontline medical staff try to deter future attempts by making first aid treatments unnecessarily painful. This practice isn’t limited to Sri Lanka, but represents a common misunderstanding that non-fatal acts of self-harm are just cries for help by attention seekers. But if instead recognised for what they are – as culturally meaningful practices transforming social relations between oneself and others – health and social service professionals will be better placed to respond with empathy and ultimately help suicidal individuals to a place where such drastic measures needn’t be taken.

Sri Lanka’s continuing self-harm epidemic represents a major challenge. After more than five decades of world-high suicide and self-harm rates, the time has come for a significant rethink in how we understand the problem. If Sri Lanka rises to meet the challenge in the same way it met the earlier challenge of pesticide regulation, an equitable solution to this protracted epidemic might be found.

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